Member Network-Providers - Berkshire Health Plan and Medicus Resource Management

What is the name and title of the provider(s) requesting to join the BHP network?

What is the providers specialty?
(If a mental health provider, please provide the area of expertise)

Is the provider joining or part of an existing group practice?
If so, please enter the group's name and TIN below.

Name

TIN

Where is the provider's primary office located?

Address:

City:

State:

Zip Code:

County

Does the provider practice in other locations?

Yes No

What are your patient care hours?

Does the provider have staff privileges at a BHP network hospital?
(Check all that apply)

	Brandywine		Sacred Heart Hospital
	Ephrata Community Hospital		St. Luke's Hospital of Allentown / Bethlehem
	Good Samaritan Regional Medical Center (Pottsville)		St. Luke's Miners Memorial Hospital
	Gnaden Huetten Memorial Hospital		St. Luke's Hospital of Quakertown
	Palmerton Hospital		St. Joseph's Medical Center
	Pottstown Memorial Medical Center		Other (please list)
	Pottsville Hospital and Warne Clinic
	The Reading Hospital and Medical Center
			None

Is the provider currently associated with a Physician Health Organization (PHO)?
If so, please list which PHO(s).

8. Who may we contact regarding this request for network participation?
Name:
Title:
Company:
Address:
City:
State:
Zip Code:
Phone:	- - Extension:
Fax:	- -
Email: